Opinion: PBMs lining their own pockets, while taking from patients
For more than two decades I have lived with an immune deficiency that is treated with a weekly infusion. Without this treatment I would live with severe and persistent infections, any one of which could be fatal. There is no alternative medical therapy available to me.
I have been able to access my medication without interruption for many years because of copay assistance programs offered by the drug’s manufacturer that help me meet my health plan’s annual out-of-pocket spending requirements. But this year I started receiving unexpected medical bills.
After dozens of hours researching and combing through the fine print of my coverage plan, I found that my pharmacy had negotiated on my behalf with a third party to negotiate “savings” which they pocket directly – to the harm of patients like me.
A Pharmacy Benefit Manager (PBM) is a third-party administrator that manages prescription drug benefits on behalf of health insurance plans, employers, and other organizations. They are also one of the driving forces in increased costs of healthcare. They are essentially middlemen who offer no direct patient care, but hugely impact a patient’s costs.
In my case I learned that while the insurance company is paid by my copay assistance program, I was charged as well. This tactic, called a “copay accumulator program” means copay assistance payments (which often come from non-profits, family members or drug manufacturers) are collected to pay for treatments, but none of the payments are then applied to a patient’s deductible or out-of-pocket cost sharing requirements.
Most patients are unaware of these programs because the language is often buried in their health plan’s fine print, and only find out like I did when they get a “surprise” medical bill.
Ultimately, my annual costs went up by $6,000.
It’s no wonder insurers and PBMs are reporting record-breaking profits on Wall Street.
Fortunately, Governor Abbott signed HB999 into law this year, which will help Texas patients afford health care by ensuring all their copays count toward their insurers’ out-of-pocket cost-sharing requirements. Texas is now one of nearly 20 states that have made these programs illegal. I was proud to stand aside patients across Texas to advocate for this legislation.
The challenge is that when one bad practice – like copay accumulators – gets struck down, the PBM’s quickly pivot to other moneymaking tactics. That includes a new program called “copay maximizer” – a close cousin of the now outlawed “copay accumulator” program. Different name, but same damaging effect for patients like me.
The good news is that Congress is taking steps to address these issues on behalf of all Americans. The U.S. Senate has introduced the Patients Before Middleman (PBM) Bill to reform these practices. The House introduced the Help Ensure Lower Patient (HELP) Copays Act earlier this year. This fall the Congressional Oversight Committee held a series of hearings about this issue, titled “Not What the Doctor Ordered.” The title alone should be an indicator of how Congress is approaching this issue. The chair of the committee described PBM practices as “deliberate, anticompetitive pricing tactics” that keep patients “from understanding how PBMs are making billions at the expense of patients and taxpayers.”
Managing a chronic condition can be exhausting. On top of the health effects that are challenging enough, piling on complicated, misleadingly worded, and deceptive practices that result in surprise medical bills is overwhelming.
I am fortunate that I have insurance to begin with. I have the ability to navigate through the tangled web of our healthcare system to understand these issues. I can take time off of work to access my treatment. I can pay for parking in the garage at the hospital. I can speak out for myself. But what about those who can’t? I worry about the mom and her son who share my same diagnosis who can’t afford an extra $12,000 a year. And the millions of Texans like them who can’t advocate for themselves.
Congress has a lot on its plate. But so do Texas patients. I urge our Texas Congressional leaders to fight for transparency, truth, and the health of millions of Texans.
Megan Ryan lives in Texas and is an advocate for changes in the healthcare system.
This article originally appeared on Corpus Christi Caller Times: Opinion: PBMs lining their own pockets, while taking from patients
